Current Thoughts on Neuroplasty vs. Neurectomy
This particular approach to managing live nerve endings of excised nerves is a refinement of migraine surgery technique pioneered by Dr. Peled.
It’s one of the reasons I travelled all the way from Boston to San Francisco to have Dr. Peled do my operations. The prospect of nerve excision was my greatest source of apprehension leading up to surgery, and seems to be for others as well.
The other reason I flew 3000 miles, twice, to Dr. Peled is his individualized approach to choosing the fate of nerves during surgery.
Some migraine surgeons have blanket policies with regards to how they deal with nerves. For example their practice may be to decide ahead of time to perform neurectomy on all lesser and third occipital nerves.
Other surgeons, like Dr. Ziv Peled, approach each and every nerve on an individualized basis and physically examine the nerve with their fingertips during surgery before determining whether to decompress or cut.
Ultimately 9/14 of my nerves were cut. The other 5 were decompressed.
Even though my greatest fear prior to surgery was nerve excision, my perspective has changed dramatically after undergoing 9 excisions and seeing that the side effects are negligible.
In fact I would say that given how minimal any numbness or odd pains are in the wake of neurectomy, and seeing that neuroma just doesn’t ever really happen, I would say that I may have even come to prefer neurectomy to neuroplasty.
There’s something about the nerve being taken completely out of the picture that is comforting, especially when the side effects are non-existent.
This may not be true of bigger nerves like the greater occipital nerve or the supraorbital nerve. Dr. Peled only cuts these nerves in rare cases when damage is severe.
Often times excision of these nerves only happens when decompression has already been attempted and pain has persisted.
So you’re still having some headaches. What’s that like? How are they different after surgery?
No More “Pain Avalanche” Effect
Prior to surgery any time that minor headache pain arose it would grow and snowball into much more severe headache episode. For example, prior to surgery I might wake up with mild headache pain in my neck, eyes and temples (actually I almost always awoke with my headaches, so this was common). Upon awakening this pain might be a 3-4 out of ten. But almost without fail this pain would grow throughout the morning. It would snowball quickly until by the early afternoon it was a 7/10 or perhaps even a full-blown 10/10 episode with nausea and vomiting.
In other words, prior to migraine surgery any headache pain meant an inevitable crippling episode. This led to deep psychological trauma around even the slightest bit of headache pain. Because the snowballing would so reliably occur, any time I had even minor headache pain a huge cloud of psychological stress would emerge as I became anxious and afraid of the oncoming storm of symptoms.
Any time I had even slight headache pain I would psychologically give in to the fact that I was done for the day and sort of check out mentally. As soon as the slightest hint of pain began my mood would swing into a sort of fight or flight self defense protection mode. Immediately I would opt out of any and all activities that required even a moderate amount of mental or physical exertion, such as social activity, thought work, writing, etc. I would throw in the towel immediately.
Since surgery this avalanching pain effect is gone. For example now I might tweak my neck boxing or sprinting and begin to feel a 3/10 level of headache pain in my right eye and temple. Prior to surgery this would have been the beginning of an inevitably much more severe episode. But now a 3/10 headache means just that – a 3/10 headache. The pain peaks early and never worsens. Actually it lessens until gradually it evaporates completely, usually within 4 or 5 hours or much sooner.
So whatever was causing this cascade effect of pain has been completely eliminated. Psychologically this has taken a lot of getting used to. The trauma from my many years of severe headaches runs so deep that still when even 3/10 headache pain arises I begin to clench up in fear of the oncoming blizzard of pain. I begin to retreat from work and lie down or meditate. But they intense pain never comes. I just sort of linger at a 3/10. Then I realize I can read or write without the pain worsening and I do. And what prior to surgery would have been a day-ending disability is now just a sort of tolerable nuisance, no different than going on with you day while dealing with a mild tummy headache or knee pain.
No More Extreme Episodes
Actually the extreme episodes ended after only my first migraine surgery. By this I mean that I haven’t had a single 8/10 episode or worse since that procedure. Since that first surgery I have vomited only once.
No More Long Episodes
Still when I have headache pain now, after surgery, I almost always awaken with it. So it begins early in the morning. As I mentioned above, before surgery it would reliably cascade into much more severe pain and would last deep into the night. Episodes usually lasted 12-24 hours even when I fasted, rested and massaged the entire time.
Now if I awaken with headache pain it almost always dissipates by noon and often much, much sooner.
I’m Pushing Myself Much Harder
These drastic reductions in my headache symptoms after migraine surgery have developed alongside a drastic change in my habits. Before surgery I walked on pins and needles in every aspect of my life, all so that I could keep the headaches at bay.
I had to be in bed before 10, had to avoid all coffee and chocolate, had to avoid mentally straining work like writing, had to avoid long hours of sitting and long hours of physical work, had to avoid running, boxing, throwing and more. I wore my Swanwick blue light blocking glasses anytime I was out after dark. I kept my displays on minimum brightness and set f.lux to maximum tungsten. I turned down social opportunities so I could be home early enough to wind down and stretch for 30 minutes before bed. You get the idea.
Sure these are all healthy habits. But I was practicing them out of fear and they came with an opportunity cost. My social life suffered–generally people hang out in the evening after work and I didn’t. I was afraid to eat anything after 4 or 5, so even though I rolled with it, dinner outings with friends were always annoying and just a little awkward. Usually I turned them down.
Of course, not being able to sit at the computer for long periods has huge economic consequences in this day and age. What do you do for work with a college degree and an inability to perform a desk job? Well I became a tradesman. This came with a pay cut (at least in the short term) and social stigma, but being on my feet performing light exercise 8 hours a day worked wonders for my symptoms. Yet trades work almost always involves a significant amount of physical contortion and exposure to harsh weather and chemicals, and I couldn’t handle much of that either. So I was never the guy who could push himself to the extreme worker faster or working long hours to get ahead. I was always one awkward movement under a car away from tweaking my neck and triggering a headache episode.
Using this “pain management” framework you could even psychoanalyze the 18 months or so I spent living at two different Buddhist monasteries. Was I just trying to manage the pain? You would think that the supposedly peaceful and serene conditions of the monastery would be a perfect place to quell headaches. Sit when you want to sit, walk when you want to walk, no stress, unlimited nature washing, no extremes in any direction. And isn’t meditation the ultimate holistic pain management tool?
But stereotype and reality do not align in the case of Thai Forest monasteries. With compressed neck posture, long hours of sitting meditation can be absolutely catastrophic to the neck. In fact I think the hundreds and thousands of hours I spent meditating put my headache symptoms completely over the edge in the years after college when those symptoms became much worse.
The bliss of nature washing is offset by the stress involved in dealing with rain, harsh sun and cold nights (you live in a tent).
But the most overlooked and, I think, severe contributing factor to my headaches while living at the monastery was spending those years sleeping on a foam pad on the ground or on a hard platform floor. Because of the firmness of such conditions, I was forced to sleep on my back (sleeping on your side requires softness).
Sleeping on my back worsened my sleep apnea, which caused me to crank my neck into contorted positions in order to open my airway while I slept. I’m certain this is why I awoke with so many headaches during that period. Still now when I awaken with headache symptoms it is most often on nights when I sleep on my back. That’s why on most nights I sleep wearing a backpack with two full sized basketballs in it (so I can’t roll onto my back).
The Forest Fire Analogy
In my case, neuralgia has always been more like wildfire than like gunshots. What do I mean? Gun shot pain would be sudden, intense, and short lived. Think “boom,” “zing,” or “zap.” If my neuralgia were like gunshots than anytime I tweaked my neck I might an intense sensation of pain that last a few seconds and then disappeared within seconds of the initial stimulus of the pain being removed.
Instead my neuralgia was always like wildfire. Something would ignite the pain–it could be as subtle as someone’s flicked cigarette cherry or as intense as a lightning bolt–and the ensuing fire would burn steady for hours or days.
Long after the initial stimulus was removed, the fire would keep burning and eventually would build up into a blazing inferno.
I would say before surgery the head and neck are like a poorly maintained forest highly susceptible to a ravaging forest fire. In this forest, there’s low, dried brush everywhere. It’s easy to spark a fire here, and the blaze would grow quickly.
After surgery, the head and neck become like a much better maintained forest. They are definitely not like the Nevada desert where you could test a nuclear bomb without fear of surroundings catching fire.
But here all the dead brush low to the ground has already been burned away and the forest floor is mostly clear. Sure, lightning might strike and a few trees might catch fire. Or maybe theres a small patch where a fire might rage temporarily before suffocating upon hitting the surrounding clear.
In other words, after migraine surgery pain still occurs. But it takes much more to trigger it, and it is a lot less intense and is shorter lived.
